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flo• t <br /> w /f Y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> . F0 '( FFCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> .Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1?3-S I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> E (Complete In Triplicate) <br /> Application is -hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No'. 1862 and the Rules and Regulations of the San Joaquin Local Health District. ' <br />` JOB ADDRESS/LOCATION 23198 South Frederick Avenue CENSUS TRACT <br /> Owner's Name Tom Emslie Phone 599:-3603 <br /> Address 23198 S . Frederick Ave. City Ripon <br /> •-- <br /> Contractor's Name Hennings Bros. ,Drilling- Co._! Inc.: Se�,�i_;116322. Phone,- 563 <br /> 1 um e . s . S jU <br /> TYPE OF WORK (Check): NEW WELL /XJ DEEPEN /-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 1 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation n A ' <br /> Domestic/private "� ae <br /> P t Drilled Dia. of Well"Casing 2n <br /> Domestic/public Driven. Gauge of Casing 12" 1 6ir <br /> X Irrigation: g XGravel Pack Depth of Grout Seal <br /> Other X Rotary Type of Grout <br /> Other Other Information # <br /> t <br /> PUMP INSTALLATION: Contractor P � <br /> Type of Pump H.P. { <br /> PUMP REPLACEMENT: / / State Work Done <br /> AT- <br /> PUMP REPAIR: <br /> / / State Work Done <br /> ESTRUCTION OF WELL:. Well Diameter Approximate Depth <br /> Describe Material and Procedure , <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and -the State -of 'California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED R TITLE <br /> (DRAW P PLAN ON REVERSE SIDE <br /> F0jr DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION E F AL INSPEC I -2 f <br /> INSPECTION BY DATE INSPECT DATE Q -- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />